1962581561 NPI number — DR. JANIS LYNNE PETERSON PH.D.

Table of content: DR. JANIS LYNNE PETERSON PH.D. (NPI 1962581561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962581561 NPI number — DR. JANIS LYNNE PETERSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
JANIS
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYBERRY
Provider Other First Name:
JANIS
Provider Other Middle Name:
P.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962581561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 POINT FOSDICK DR NW
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
GIG HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98335-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-851-3808
Provider Business Mailing Address Fax Number:
253-851-3188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 POINT FOSDICK DR NW
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
GIG HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98335-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-851-3808
Provider Business Practice Location Address Fax Number:
253-851-3188
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1248 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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